Tuesday, 26 July 2011

A VIEW FROM THE OTHER CHAIR

The final piece in my mental health feature comes from jules, a trainee clinical psychologist who gives an interesting insight into the role and feelings of a person working therapeutically with clients. Jules graduated from Liverpool University many moons ago, and worked as an academic researcher in forensic mental health, working on projects for the University of Liverpool and Manchester University, the Department of Health and Prison Health.

She successfully bid for an NHS R&D National Training Fellowship in Forensic Mental Health to do a PhD at Manchester (nee Carlisle) on the psychosocial needs of women in prison. Jules is also a contributing author in Brooker. C. and Repper J. (Eds) (2008) Mental Health – Policy and Practice. London: Churchill Livingstone (Chapter 6 – Women and Mental Health).

Jules is currently a Trainee Clinical Psychologist at University of Liverpool... feeling like she's never quite left school...

This blog is my own opinion and not that of the university, the NHS or that of the British Psychological Society.

As a psychologist it would be gravely unprofessional for me to divulge the contents of any therapy sessions I had been involved in. And I would never dream of betraying my clients. However there is something to be said for the experience of being a therapist; one which changes with each client.

By the time a person comes to therapy, they may have experienced their problems for a considerable length of time. They may have tried many ways to resolve their problems, some helpful, and some not so. Crucially there is often a stereotype and expectations of coming to therapy which may impact on how it actually goes.

Clients can feel worried that the psychologist will analyse their every word or move; be subject to uncomfortable – almost telepathic - scrutiny, that they will be asked to behave in ways that goes against what they want, that their persona will be disapproved of.

In fact shame and guilt play a familiar part in many common mental health problems. It is therefore unsurprising that the fear of these feelings being exposed is of concern.

Importantly the client often feels that the therapist will judge them, and judge them in comparison to the therapist’s own life (with the fantasy being that the therapist must be a person who is ‘emotionally sorted’, and have a perfect set up).

What about me? What are my expectations of my clients? How do I feel?

I’m not an automaton. I too have feelings; I have experienced complex life events; I have relationships with family and friends that are not straightforward, loving and balanced; I have sometimes handled things ‘badly’.

What about my mental well-being? Have I suffered with mental health problems? Is it wrong for a therapist to offer therapy if they have experienced the same thing as the client? Some clients insist that therapy will only be successful if the therapist discloses experiences which are in some way similar to theirs. This of course isn’t true.

What is important is that we have a space to get to know the situation, and then each other in ways that are therapeutic. This does not mean that we become sharing confidants – there must be no facebook or texting each other – we never become friends. However there needs to be an openness to ‘like’.

This might not be instant – either for the client or me. I have had clients whose beliefs are of stark contrast to my own. The client however will never know this. There are those whose behaviour is abhorrent –yet for my part, the humanitarian in me just starts with two human beings in a room. One will tell the other about their life and situation. I listen, observe and feedback - slowly allowing the person to tell their story, fill in the details of the background, and the colour of the feelings and emotions.

I have to be patient. I try to see how the person arrived at this point, imagining (through the words they use) how they feel in the circumstances. I try to be mindful of who I am to them, and who they are to me.

THERAPEUTIC ALLIANCE – who am I to you?

Am I your enemy? Your saviour? Your Mother? Your friend?

I am none of these, but I have definitely felt like the mother of many clients, the betrayer to others. This is always difficult. I’m not a strict psychodynamic practitioner, but I always explore what they expect from therapy (which can be very different to what they want, or what they say they want), and explore their feelings in relation to me. I want to know what they think of my role. It can be really important – especially if they hero worship or come across as dependent. These can be tricky situations to manage well.

Working together the therapist and client form a therapeutic alliance. This relationship is of great significance to the success of the therapy itself, and like all relationships it runs a course which is not always smooth.

This is a good thing. It has been shown by Hovarth and colleagues that when therapy is tricky, and it feels like the relationship between the client and therapist has some tension, those who can weather that tension (or any ruptures in the process), fare better in therapeutic outcome measures. In essence it’s like modelling emotionally healthy relationships; something some clients may have never really experienced.

In psychological therapies it is important that the therapist doesn’t just empathise with the client’s plight, which might seem kind, gentle, nicey-nicey or collude with them against the world. They must work with the client in a way that helps the client look at themselves, their role, potential traps and ways to avoid or manage pitfalls. This can be uncomfortable for some, and downright painful for others. Sometimes in therapy, I have bore the brunt of the client’s anger – in that coming to explore their feelings and role has left them feeling too exposed, caused acute embarrassment, or guilt.

It has been all too easy for some to manage that guilt by saying to me “This is your fault”. “I don’t know why I come here, it’s not helping.” “I feel shit.” Providing I have paced and managed the therapy well, I never feel offended or frightened by the client’s anger. I like to see new emotions addressed.

It generally bodes well. I do however help share responsibility – rightly or wrongly (some therapists would disagree).

The client may not have discovered their anger without coming to therapy so in some way I do have a hand in it. It’s what the client does with that anger that is of most concern to me. I don’t want them to hit self destruct, spiral out of control, (however some do, self destructive behaviours can be comforting and ‘normal’.)

As long as they keep coming back to therapy, we’re likely to be on the right track. Similarly I don’t want them to over control, or contain that emotion – I find myself willing them to safely express. I hope I guide them to make their own decisions, take responsibility for their actions, but in a way that is right for them. I often wait, metaphorically with baited breath, to see if the client returns the following week; to see how they handled themselves after the session.

I have a set of predictions of sorts, in which I evaluate against how I think the client experienced the session, and how they might respond to feelings or circumstances (based on what they may have told me about how they typically handle things, and based on my knowledge of psychological mechanisms).

I generally resist the urge to follow-up and check on them (unless it is a part of the therapy to do so). But I want to know that they’re safe... as any parent does a child who is out without them. Essentially it feels like healthy re-parenting. Again me in mother mode...

Mother mode is clearly comfortable for me, but is it right? Well, not all clients bring that out in me – but it is the most common part of me as therapist. I watch for being patronising – or perhaps matronising.

Not all clients want or need (or like!) a mother figure, and not all clients need ‘re-parenting’. It is certainly not a requisite role to successful therapy. Indeed one could argue that it sets up a power dynamic which may be unhelpful. There have been times when I have felt blocked by a client (those who find it hard to talk about their experiences or emotions), I have felt somewhat intimidated – not physically, but certainly that the client is going to tell me what they think I need to know and no more.

Such attempts to control therapy can occur in seemingly the most innocuous sessions, and can be managed over time when the client feels safe (emotionally) with me. Perseverance pays, along with a gentle manner – one in which mother can often be unwelcome.

There are clients who disclose that they pose a risk to themselves or others. That brings out a whole load of feelings in me. It is different for each therapist. But for me I feel a sense of responsibility, of fear, of concern. I guess for me it wouldn’t be normal otherwise. But the difference for me is that I’m not so overwhelmed with the other person’s emotion that I can’t see clearly, or help them explore what they feel or want to do.

I’m also not so overwhelmed by my own feelings, which amongst other things can occasionally contain helplessness, inadequacy and anxiety. Their therapy is not about me. Yet, I am a player in that relationship. My agenda is help, safety and to do no harm. Fortunately, I’m in a position to receive quality clinical supervision, which allows me to explore my feelings in relation to any client or therapeutic work and helps to keep all on track.

There are clients with whom the therapeutic experience feels far more fraught - an engagement with another’s emotional impulses which may be difficult to tame, their difficulties not only stem from a variety sources (e.g. childhood, major life events, biology/physiology), but the expression of problems in one person can be various – depression, mania, anxiety, paranoia, voices and OCD. Whilst I don’t necessarily feel overwhelmed by that, to focus on it in writing has tended to force me to analyse and formulate which is something I didn’t want to do here.

This blog does not do justice to exploring other important therapeutic roles of transference and counter-transference. Indeed my thoughts and feelings about being in the therapeutic role are my own, and may be in contrast to the experiences of other therapists. It must also be said that this reflects generic therapeutic practice. It does not reflect how it feels to see oneself in therapy – faced with a client who is like me; has my life; has my experiences; has problems I have had.

It does not reflect how it feels to see familiar stories – the man who is like my dad, or brother, the woman whose behaviour is reminiscent of a close friend, or the times when my own life events dictate the way I work. These issues will come up over my career, I’m sure of that - Resonating and reverberating, jolting and jarring my thoughts and emotional responses. I just hope that the quality of my care (for myself and others) is such that I can maintain the healthy relationship with my clients whatever the circumstances.